All India Institute of Medical Sciences
Clinician Academcian Researcher
Jodhpur, Rajasthan | India
Main Specialties: Adolescent Medicine, Allergy & Immunology, Child Abuse Pediatrics, Child Neurology, Dermatology, Hematology, Hematology & Oncology, Infectious Disease, Medical Genetics, Neonatal-Perinatal Medicine, Pediatric Critical Care Medicine, Pediatric Hematology-Oncology, Pediatric Nephrology, Pediatric Rheumatology, Pediatrics
Additional Specialties: Pediatric Hematology
My work as senior resident at Department of pediatrics (APC),PGIMER,Chandigarh since July 2014 had working experience of pediatric emergency,PICU,NICU,OPD,General ward and various pediatric sub-specialties like Nephrology,Neurology,Psychology,Social-Pediatrics, Immunization Clinic, Nutritional Clinic,Immunodeficiency,Rheumatology, Hematology and Oncology Clinic, Growth Clinic, Genetic and Metabolic Unit, Pulmonology and Allergy Clinic,Cardiology,Endocrinology,Neonatology and Gastroenterology and Hepatology units.
The work includes Indoor and Outdoor patient’s management, efferent critical procedures regarding patient management, ward rounds, MD resident teaching round and bed side teaching, night duties. Academic activities like classes for resident, clinic-pathological teaching activities, classes for nurses and other paramedical staff. Consultations to various inter specialties regarding case management. Also, had work experience of oral and poster presentation at national and international conferences.
Research activities like various studies, reviews and case report publication. Worked as management in-charge for coordination of various academics, non-academics and patient management related activities. I also provided services at peripheral community health Centre linked to PGIMER, children’s home, Thalassemic societies and mother Teresa Centre during my work period. Also, worked with Telemedicine department for assisting the linked remote hospital for consultation regarding difficult case management. Attended various seminars, short training programs like NALS, PALS and different symposium and skill up-gradation programs during my working periods.
Had adequate independent hand on working experience of Fiber-Optic Bronchoscopy, I Endoscopy, Peritoneal dialysis machine and Ventilator setting and functioning, Renal Biopsy, Liver Biopsy, Bone Marrow, Chemotherapy, LP, Ventricular tap, Invasive Central Line, Intraosseous line, Peritoneal dialysis and Endotracheal Intubation.Also worked at Dr S N Medical College Jodhpur as Assistant Professor in department of Pediatrics.
Currently working at AIIMS Jodhpur as Assistant Professior.
Future Interest: To work on preventive pediatrics including neonatology for uplifting of Children, Society, Country and the whole Humanity. To develop preventive pediatric as core pediatric subspecialty, perticularily to help poor population and nation.
Primary Affiliation: All India Institute of Medical Sciences - Jodhpur, Rajasthan , India
Indian J Child Health
Verma and Didel Cold abscess following vaccinationVol 3 | Issue 1 | Jan - Mar 2016 Indian J Child Health 76Case ReportCold abscess of thigh following inadvertent vaccination in an infantSanjay Verma, Siyaram DidelFrom Department of Pediatrics, Advanced Pediatric Centre, Post-graduate Institute of Medical Education of Research, Chandigarh,IndiaCorrespondence to: Dr. Sanjay Verma, House No. 3001/1, Sector 38-D, Chandigarh - 160 036, India. Phone: 91-7087008482.E-mail: email@example.comReceived –04 January 2016 Initial Review – 04 February 2016 Published Online – 28 March 2016AbstractLocalized abscess in the same site of bacillus Calmette-Guerin (BCG) vaccine is a known complication. However, the occurrence ofsuch abscess at other sites is uncommon. We, hereby, report a case of 4-month-old female child who developed a swelling at left thighfollowing intramuscular injection at 6 weeks vaccination. Aspiration cytology of abscess showed granulomatous inflammation andpositivity for acid-fast bacilli. The exact etiology for this presentation is unknown; however, wrongful inoculation of the BCG vaccinein place of DPwT vaccine at 6 weeks could be suspected. Mycobacterium should be considered in any unexplained soft tissue abscessin areas of the world where tuberculosis is prevalent.Key words: Cold abscess, Thigh, VaccinationLocal adverse reactions following intramuscular injection of vaccines are a common and localized abscess in the same site of bacillus Calmette-Guerin (BCG) vaccineis also known. However, the occurrence of such abscess atother sites is uncommon. We report a rare association between6 weeks intramuscular vaccination and development of coldabscess possibly due to non-tubercular Mycobacterium bovisand discuss pertinent issues.CASE REPORTA 4-month-old female child (birth weight 3.1 kg) presented toour outpatient department with a swelling on the anterolateralaspect of her left thigh. This swelling appeared, for the firsttime, few days after receiving intramuscular vaccination inthe left thigh, at the age of 6 weeks and was persisting till thetime, child presented to us (Fig. 1). There was no history offever, weight loss, or cough; and no history of contact withtuberculosis (TB) patient. Examination of the left thigh revealeda soft, fluctuant swelling of 3.5 cm × 1.5 cm in size; which wasnot warm, non-tender and non-pulsatile (Fig. 1). There wasno joint restriction and no similar swelling at any other site.There was a BCG scar in the left upper arm and other systemicexamination was unremarkable.Laboratory test showed total leukocyte count of11,800/mm3 (68% neutrophils, 32% lymphocytes); hemoglobin12.1 g/dl; erythrocyte sedimentation rate 17 mm/h; C-reactiveprotein 10.8 mg/L; liver function test and coagulation profilewere normal; blood culture was sterile and serology for HIVwas negative. X-ray of hip joint, thigh and spine showed nobony abnormality or any evidence of osteomyelitis. On furtherinvestigations (chest X-ray, gastric aspirate for acid fast bacilli(AFB) and ultrasound of abdomen, hip joint and cranium),no evidence of TB at any other site was found. Screening ofcaregivers for TB was also non-contributory. Child had receivedBCG vaccine at birth in left upper arm as per country’s nationalvaccination schedule. Mantoux test (with 5 TU purified proteinderivative) done on right forearm, showed induration of 9 mmafter 72 h.Fine needle aspiration cytological (FNAC) showedcaseating granuloma suggestive of TB and staining for AFBwas positive and culture from aspirate was sterile. Polymerasechain reaction for Mycobacterium TB was done, which wasnegative. Since the swelling and the disease did not progressin last 10 weeks, other investigations were not suggestive ofprogressive tubercular disease, and child was thriving verywell; we presumed it to be non-tubercular Mycobacterium.Parents were reassured, no anti-tubercular therapy was advisedand regular follow-up was planned. Swelling improved onfollow-up and completely disappeared by 6 months of agewithout any specific treatment and child was growing well onfollow-up at 1 year of age (Fig. 2).DISCUSSIONIn our country, BCG vaccination is given to all newborns atbirth as per WHO recommendations . Cold abscess refersto an abscess that lacks the intense inflammation usuallyVerma and Didel Cold abscess following vaccinationVol 3 | Issue 1 | Jan - Mar 2016 Indian J Child Health 77associated with bacterial infections . In developing world,TB still remains the most common cause for cold abscess.This usually follows involvement of adjacent bones and coldabscess of psoas muscle is generally one of the characteristicmanifestations of spinal TB (Pott’s spine) [3,4].In our child, there was no evidence of TB of spine, thigh,pubis, or any other parts of body; there was a clear historyof the appearance of swelling at the site of intramuscularDwPT injection. In context of AFB positivity and FNAC fromswelling suggestive of TB, it was difficult for us to explain theorigin of infection. A possible explanation could be inadvertentintramuscular administration of BCG vaccine at 6 weeks, inplace of DwPT vaccination by vaccinator. Although we couldnot prove this, as vaccine at 6 weeks was received at anothervaccination center.On literature review, we could find out few case reports ofdevelopment of tubercular abscesses following intramuscularinjections in immunocompetent infants [5-9]. Such an abscessat the site of intramuscular injection could be either becauseof injection with syringe contaminated with Mycobacteriumtuberculi or because of inadvertent administration of BCGvaccine intramuscularly. Although culture from aspirate in ourcase was sterile, we could not prove whether it was becauseof syringe transmission of M. tuberculi from another case orM. bovis from BCG injection. Because of the availability ofdisposable syringes in the present era for every vaccination,possibility of contamination seems less likely. Tubercularinfection at the site of injection following intramuscular BCGvaccination is given mistakenly in place of DwPT vaccinationseems more likely in our case. Unfortunately, there are fewsimilar case reports of inadvertent intramuscular injectionof BCG vaccine to infants in past as well, where prolongedlocal reaction and swelling have developed [7,9,10]. Being aprogrammatic error, this should become a type of adverse eventfollowing immunization as per WHO definition.Usually, no treatment is needed for non-Mycobacteriumtuberculous infections in immunocompetent children. However,immunocompromised children or those having severe diseasemay need antibiotic therapy for 12-24 months. After aspiration,swelling decreased in our child and gradually disappearedwithout any anti-tubercular therapy. There is no consensus forthe best management of this complication; although, healingmight be prolonged without anti-tubercular therapy . Ourcase indicates that any child who present with unexplained softtissue swelling, accidental BCG injection causing tuberculousabscess should be considered in the differential diagnosis;especially, in those areas where children receive BCG vaccinein their immunization schedule. This case also highlights thepossible adverse effects that could happen during vaccinationand the need to address these issues.CONCLUSIONCold abscess at intramuscular injection sites followingvaccination could be due to inadvertent administration ofintramuscular BCG vaccine in infants. We wish to sensitizepediatricians and other medical fraternity about the possibilityof such adverse reaction following vaccination, especiallywhen adjacent joints and bones are normal.REFERENCES1. World Health Organization. BCG vaccine. WHO Position Paper.Wkly Epidemiol Rec. 2004;79(4):27-38.2. Jackson R, Stephens L, Kelly AP. Cold subcutaneous abscesses.J Natl Med Assoc. 1990;82(10):733-6.3. Millar TM, McGrath P, McConnachie CC. Tuberculosis of thespine presenting with a cold abscess through the lumbar triangleof Petit. Clin Anat. 2007;20(3):329-31.4. Bevan PG. Tuberculosis of pubis presenting as a cold abscess ofthe thigh. Br Med J. 1955;2(4943):832-3.5. Agrawal A, Jain A. Tuberculous cold abscess. Indian J Pediatr.2007;74:771-3.6. Abdelwahab IF, Kenan S, Hermann G, Klein MJ. Tuberculousgluteal abscess without bone involvement. Skeletal Radiol.Figure 1: Soft tissue swelling in the left thigh at presentationFigure 2: Soft tissue swelling in the left thigh at 1-yearfollow-upVerma and Didel Cold abscess following vaccinationVol 3 | Issue 1 | Jan - Mar 2016 Indian J Child Health 781998;27(1):36-9.7. Pasteur MC, Hall DR. The effects of inadvertent intramuscularinjection of BCG vaccine. Scand J Infect Dis. 2001;33(6):473-4.8. Okazaki T, Ebihara S, Takahashi H, Asada M, Sato A, Seki M,et al. Multiplex PCR-identified cutaneous tuberculosis evoked byMycobacterium bovis BCG vaccination in a healthy baby. J ClinMicrobiol. 2005;43(1):523-5.9. Al Namshan M, Oda O, Almaary J, Al Jadaan S, Crankson S,Al Banyan E, et al. Bacillus Calmette-Guérin-related coldthigh abscess as an unusual cause of thigh swelling in infantsfollowing BCG vaccine administration: A case series. J Med CaseRep. 2011;5:472.10. Sharma J, Sharma T, Bhatt GC, Bhargava R. Isolated coldabscess of the thigh in an immunocompetent infant. Trop Doct.2014;44(4):221-2.Funding: None; Conflict of Interest: None Stated.How to cite this article: Verma S, Didel S. Cold abscess of thighfollowing inadvertent vaccination in an infant. Indian J ChildHealth. 2016;3(1):76-78.
International Journal of Scientific Reports
International Journal of Scientific Reports | July 2015 | Vol 1 | Issue 3 Page 169International Journal of Scientific ReportsDidel SR et al. Int J Sci Rep. 2015 Jul;1(3):169-171http://www.sci-rep.com pISSN 2454-2156 | eISSN 2454-2164Case ReportAcute sensorineural hearing loss in a child with typhoid feverSiya Ram Didel1, Harsimran Tiwana2, Piyush Mittal1, Devi Dayal1*, Sandeep Bansal2INTRODUCTIONInfection with Salmonella typhi may result in diffuseorgan involvement. Although most infections manifestwith classical clinical features of enteric fever, atypicalpresentations have been increasingly observed over pastfew decades probably due to prior antibiotic use,incomplete treatment with common antibiotics andmultidrug resistance in endemic areas.1 Of all the atypicalfeatures of enteric fever, cochleovestibular involvementresulting in sensorineural hearing loss (SNHL) has beenreported rarely in children as well as adults.2 Mostpatients show complete recovery after effectiveantibiotics use, but permanent loss of hearing has alsobeen reported.3It is important to recognize SNHL as a complication ofenteric fever to prevent delays in clinical suspicion ofdisease that often happens when patients present withatypical manifestations.1In this communication, we describe a child whopresented with fever and acute severe hearing loss whichreversed completely after treatment of enteric fever.CASE REPORTThis 8 year old boy had moderate to high grade fever for2 weeks, and developed headache with decreased hearinga day prior to presentation. The hearing loss was bilateraland sudden in onset. There was no history of eardischarge, exposure to ototoxic medications, trauma,altered sensorium or facial deviation. There was noassociated vertigo, ear discharge or tinnitus. He hadreceived cefixime in inadequate doses. On physicalexamination, he appeared pale and toxic and axillarytemperature, pulse rate, respiratory rate and bloodpressure were recorded as 103°F, 123 per min, 28 permin and 100/70 mmHg respectively. There was noeschar, icterus or lymphadenopathy. Abdominalexamination revealed hepatosplenomegaly with liverpalpable 4 cm below right costal margin (liver span 11cm) and spleen palpable 4 cm below left costal margin.Rest of the systemic examination was normal. In cranialnerves examination, test for glossopharyngeal nerveswere impaired bilaterally. Tuning fork test could not beperformed as child was unable to comprehendinstructions. Rest of the cranial nerves functions werewithin normal limits. There was no nystagmus. Otoscopyshowed normal tympanic membranes. Based on theABSTRACTTyphoid fever is a systemic febrile disease caused by Salmonella typhi and may lead to involvement of virtually anyorgan system in the body. Cochleovestibular involvement resulting in acute sensorineural hearing loss (SNHL) hasbeen reported as a rare complication and may result in permanent deafness. We describe here a child who developedmoderate but reversible SNHL associated with typhoid fever.Keywords: Typhoid fever, Acute sensorineural hearing loss, Deafness, Child1Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India2Department of Otolaryngology, Postgraduate Institute of Medical Education and Research, Chandigarh, IndiaReceived: 05 June 2015Accepted: 19 July 2015*Correspondence:Dr. Devi DayalE-mail: firstname.lastname@example.org; email@example.comCopyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed underthe terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercialuse, distribution, and reproduction in any medium, provided the original work is properly cited.DOI: http://dx.doi.org/10.18203/issn.2454-2156.IntJSciRep20150353Didel SR et al. Int J Sci Rep. 2015 Jul;1(3):169-171International Journal of Scientific Reports | July 2015 | Vol 1 | Issue 3 Page 170history and clinical examination, enteric fever, scrubtyphus and viral infections were considered as theprobable initial diagnoses.Investigations revealed haemoglobin of 7.5 g/dL, totalleukocyte count of 6000 (neutrophils 70%, lymphocyte27%, monocytes 2%, eosinophils 1%) and platelet countof 120000/mm3. Serum sodium, potassium, urea andcreatinine were 133 mEq/L (normal 135-145 mEq/L), 5.0mEq/L (normal 3.5-5.0 mEq/L), 20 mg/dL (normal 5-18mg/dL) and 0.5 mg/dL (normal 0.3-0.7 mg/dL)respectively. Liver function tests showed serum alaninetransferase 126 U/L, serum aspartate 229 U/L, alkalinephosphatase 284 U/L, serum albumin 2.0 gm/dL and totalserum bilirubin of 0.7 mg/dL. C-reactive protein was 46.8mg/L (normal range, 0.052-3.2 mg/L). Chest radiographdid not show any abnormality. Widal test showed THtitre of 1:320 and TO titre <1:40. Blood culture waspositive for Salmonella typhi which was sensitive toceftriaxone, ampicillin and chloramphenicol. Serologicaltests for scrub typhus and herpes simplex virus werenegative. Multiple peripheral smear examinations formalarial parasites as well as rapid card test (QDx MalariaPv/Pf, Nicholas Piramal India) were negative.On pure tone audiometry (PTA) hearing loss was foundto be 57/62 db in right ear and 57/57 db in left ear,indicating bilateral moderate SNHL (Figure 1a). Tonedecay test was normal, thereby ruling out anyretrocochlear pathology. Child was started on intravenousceftriaxone, oral acyclovir and prednisolone. Acyclovirwas omitted after culture showed positivity forSalmonella typhi. Repeat PTA 7 days after startingtreatment showed improvement (42/45 db in right ear and42/42 db in left ear (Figure 1b). Improvement in generalwell-being and appetite occurred over the first few daysand he became afebrile by day 8 of hospitalization. Serialhematological and biochemical parameters also showedconsistent improvement. Child was discharged on oralcefixime to complete the antibiotics course for 2 weeks.Audiogram repeated 1 month later showed essentiallynormal hearing (Figure 1c).Figure 1: Pure tone audiograms at presentation (a), after 1 week (b) and 1 month (c).DISCUSSIONSudden SNHL is a rare manifestation of typhoid fever.1,2Only a few cases have been described in children.1-4 Thehearing loss usually occurs from second to third week ofillness, and may occasionally become permanent.2,3 In ourpatient, hearing loss appeared on day 13, started showingimprovement from day 21, and recovered completely byday 44 of illness. Similar hearing loss is reported morecommonly in our country in patients with scrub typhus,which we excluded by serological tests.5 Other causes ofsudden SNHL, such as viral infection of the labyrinth orcochlear nerve, vascular insult, perilymphatic hypoxia,intralabyrinthine membrane rupture, inflammatory andmetabolic causes, and immune-mediated inner ear diseaseare usually reported in adults.6The exact mechanism of hearing loss in typhoid fever isnot established. In a study of six cases of pathologicallyconfirmed cochleovestibular lesions due to typhoid fever,host susceptibility, endotoxins, arteritis, and ischemiaDidel SR et al. Int J Sci Rep. 2015 Jul;1(3):169-171International Journal of Scientific Reports | July 2015 | Vol 1 | Issue 3 Page 171were the factors believed to have resulted in developmentof these lesions and the consequent hearing loss.2Cochleo-vestibulitis may also occur secondary toendotoxinemia and cytokine mediated damage.7The treatment of SNHL in typhoid fever involveseffective antibiotic therapy for the infection.Corticosteroids have a limited beneficial effect onhearing recovery and their role is debated. Oral,intratympanic or pulse steroids are commonly used inidiopathic SNHL which is presumed to be due tosubclinical viral labyrinthitis in most cases.8 Since theetiology of SNHL was unclear initially, we had initiatedoral prednisolone in our patient presuming a viralinfection of the labyrinth or cochlear nerve. It is possiblethat the hearing recovery was entirely due to the effectiveantibiotic use, but the contribution of steroids tosuppression of cochleovestibular inflammation andhastening recovery of SNHL cannot be completelyexcluded in our patient.In conclusion, we report a rare complication of SNHL ina child with typhoid fever. This communication shouldserve to alert the treating physicians to consider typhoidfever in the differential diagnosis of a child with feverand hearing loss, and initiate antibiotic therapy promptly.Funding: No funding sourcesConflict of interest: None declaredEthical approval: Not requiredREFERENCES1. Dutta TK, Beeresha, Ghotekar LH. Atypicalmanifestations of typhoid fever. J Postgrad Med.2001;47(4):248-51.2. Escajadillo JR, Alatorre G, Zárate A. Typhoid feverand cochleovestibular lesions. Ann Otol RhinolLaryngol. 1982;91(2 Pt 1):220-4.3. Faucher B, Zaegel O, Niang A, Ba Fall K, MbayePS. Permanent deafness following typhoid fever:case report from Dakar, Senegal. Med Trop (Mars).2009;69(1):73-4.4. Richens J. Typhoid in the highlands of Papua NewGuinea 1984-1990: a hospital-based perspective. PN G Med J. 1995;38(4):305-14.5. Mahajan SK, Bakshi D. Acute reversible hearingloss in scrub typhus. J Assoc Physicians India.2007;55:512-4.6. Stachler RJ, Chandrasekhar SS, Archer SM,Rosenfeld RM, Schwartz SR, Barrs DM, et al.Clinical practice guideline: sudden sensorineuralhearing loss. Otolaryngol Head Neck Surg.2012;146(3 Suppl):S1-35.7. Edelman R, Levine MM. Summary of aninternational workshop on typhoid fever. Rev InfectDis. 1986;8(3):329-49.8. Chen WT, Lee JW, Yuan CH, Chen RF. Oralsteroid treatment for idiopathic sudden sensorineuralhearing loss. Saudi Med J. 2015;36(3):291-6.Cite this article as: Didel SR, Tiwana H, Mittal P,Dayal D, Bansal S. Acute sensorineural hearing loss in achild with typhoid fever. Int J Sci Rep 2015;1(3):169-71.
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Acta Virol 1975 Nov;19(6):501-8
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